INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC

A SUMMARY OF THE FEBRUARY 2009 SUMMIT

Andrea M. Schultz, Samantha M. Chao, and J. Michael McGinnis, Rapporteurs

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

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Andrea M. Schultz, Samantha M. Chao, and J. Michael McGinnis, Rapporteurs

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the National Academies. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13: 978-0309-13901-4 International Standard Book Number-10: 0-309-13901-5 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334- 3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2009. Integrative medicine and the health of the public: A summary of the February 2009 summit. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE FOR THE SUMMIT ON INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC1 RALPH SNYDERMAN (Chair), Duke University CAROL M. BLACK, Academy of Medical Royal Colleges CYRIL CHANTLER, The King’s Fund ELIZABETH A. GOLDBLATT, Academic Consortium for Complementary and Alternative Health Care ERMINIA GUARNERI, Scripps Center for Integrative Medicine MICHAEL M. E. JOHNS, Emory University RICHARD P. LIFTON, Yale University School of Medicine BRUCE S. McEWEN, The Rockefeller University DEAN ORNISH, Preventive Medicine Research Institute and University of California, San Francisco VICTOR S. SIERPINA, University of Texas Medical Branch ESTHER M. STERNBERG, National Institute of Mental Health ELLEN L. STOVALL, National Coalition for Cancer Survivorship REED V. TUCKSON, UnitedHealth Group SEAN TUNIS, Center for Medical Technology Policy Study Staff JUDITH A. SALERNO, Executive Officer J. MICHAEL McGINNIS, Senior Scholar SAMANTHA M. CHAO, Program Officer (through February 2009) ANDREA M. SCHULTZ, Associate Program Officer (from December 2008) KATHARINE BOTHNER, Research Associate (from December 2008) JOI WASHINGTON, Senior Program Assistant CATHERINE ZWEIG, Senior Program Assistant Institute of Medicine Consultants NEIL E. WEISFELD, NEW Associates, LLC VICTORIA D. WEISFELD, NEW Associates, LLC 1 The role of the planning committee was limited to planning and preparation of the summit. This document was prepared by rapporteurs as a factual summary of what was presented and discussed at the summit. v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Review Com- mittee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institu- tional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Brent A. Bauer, Mayo Clinic Susan Frampton, Planetree Michael M.E. Johns, Emory University Bruce McEwen, Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, The Rockefeller University Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Ada Sue Hinshaw, Uniformed Services University of the Health. Appointed by the National Research Council and Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring com- mittee and the institution. vii

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Foreword Health is a personal matter, as is the way each of us chooses to inte- grate concerns about health into our lives. Like a Rorschach blot, the no- tion of integrative medicine, or integrative health, means different things to different people. As an approach to enhancing health, integrative health seeks to combine the best scientific and evidence-based ap- proaches to care with a focus on the full range of needs of the individual. Integrative medicine seeks to enable everyone to maintain their health insofar as possible, and to be empowered in partnering with health care providers when illness occurs. With this approach, patients can be more effective stewards of their own health and wellness. This publication, Integrative Medicine and the Health of the Public: A Summary of the 2009 Summit, provides an account of the discussion and presentations of the two-and-a-half day summit in Washington, DC, held February 25–27, 2009. While this summary captures the discussion, it cannot adequately convey the energy and enthusiasm of the partici- pants who filled the auditorium throughout the event. The Institute of Medicine (IOM) was honored to host such a large and diverse group to discuss such a timely topic, especially at such a critical time in American health care policy making. Under the direction of Ralph Snyderman, the summit planning com- mittee assembled an outstanding group of speakers and discussants who provided valuable insights on the potential and limitations of integrative health care, models that might be most conducive to its delivery, the mul- tiple dimensions of scientific endeavor that intersect as its support base, and possible economic implications and incentives. Participants had an exceptional opportunity to examine the role and value of integrative ix

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x FOREWORD medicine in meeting health needs and overcoming fragmentation in the health care delivery system. The summit discussions were fruitful and collaborative, and I believe that every participant came away from the meeting having learned some- thing each did not know before. It is my hope that this publication will advance thoughtful consideration of integrative medicine and extend the enthusiasm that was ignited at the summit. I would like to thank the Bravewell Collaborative for their spirit of partnership and support of this activity, Ralph Snyderman for his leader- ship and guidance, the planning committee for their commitment and wisdom, and the IOM staff for their hard work and dedication. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine

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Preface “Life, liberty, and the pursuit of happiness,” a phrase taken directly from the Declaration of Independence, indicates the basic values identi- fied by the founders of our nation. Of the three, life is the most funda- mental as without it, liberty and the pursuit of happiness are meaningless. Health, of course, is the underpinning of life and therefore, it is puzzling that there is so little general demand for an explicit public emphasis on nourishing health as a personal and social resource. Indeed, despite spending enough on “health care” to threaten our economy, our country is rife with chronic disease, is facing a growing epidemic of obesity and ill health, has a system of care that focuses on the treatment of episodes of disease rather than promoting health or coherently treating disease when it occurs, and there are 47 million Americans without health insur- ance. It is well recognized that our approach to health care is reactive, spo- radic, uncoordinated, and very expensive. Clearly, we are capable of far better health care delivery and more innovative approaches toward im- proving the health and well-being of our citizens. The concept of the Summit on Integrative Medicine and the Health of the Public arose from these basic premises that health and well-being represent our most valued assets and that our current delivery system is deeply flawed in its capac- ity to safeguard those assets. To improve health, we must address not only health care delivery but also how to engage and inform the patient (person), so they effectively achieve better health. Indeed, there are mod- els and examples of more coherent approaches to enhancing health and well-being and preventing and caring for chronic disease. Critical to such approaches is the integration of the best of conventional care with the full engagement of an informed patient along with coordination of those xi

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xii PREFACE therapies and services shown to improve outcomes. Thus, integration of health care to include a full range of capabilities for enhancement of health and wellness, prediction and prevention of chronic disease, as well as participation by the patient form a common theme for ways to address our current health dilemma. These are concepts well recognized and supported by the members of the Bravewell Collaborative, a philanthropic organization committed to improving health through integrative approaches. Through a long- standing friendship with the leadership of this organization, particularly Christy Mack and Diane Neimann, we discussed how their organization could best further their agenda to improve health and well-being through integrative care. I suggested they contact the Institute of Medicine (IOM), our nation’s most respected organization regarding the evaluation of health care issues. As a result of their deliberations with IOM Presi- dent Dr. Harvey Fineberg and the IOM leadership, the IOM agreed to sponsor a major national summit bringing together broad program, scien- tific, and policy experts to review the issues and state of the science for integrative health and health care, and to discuss the feasibility of various existing models or new models as potential solutions to our current prob- lems. The intent of summit organizers was to organize an event that of- fered a venue for a diverse group of stakeholders to come together for candid discussion of topics related to integrative medicine and the ad- vancement of the field; the summit was not designed to elicit a consensus or a set of recommendations from the participants or the planning com- mittee. The IOM assembled a highly experienced and knowledgeable plan- ning committee, which I was privileged to chair, and we launched a year of intensive work. None of us likely anticipated fully the time commit- ment involved, but for each of us the effort was a work of love. Along with support from the superb staff of the Institute of Medicine, particu- larly Dr. Michael McGinnis, Samantha Chao, and Andrea Schultz, we were able to assemble the program for the February 25–27 meeting de- scribed in this summary. We hoped for an audience of up to 500, but once the summit was announced, over 700 people registered, and we were able to accommodate about 600. The speakers and participants in- cluded a broad array of leaders in multiple fields. The audience, likewise, was outstanding and participated fully and effectively. The summit not only far exceeded our highest expectations, it was an event that led to the bonding of attendees, informed our outlook, and en- hanced our commitment to work for positive change. During multiple

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xiii PREFACE discussion venues, many facets of integrative care were explored. Of course, no single approach could be identified as the solution, but it was broadly agreed that health and health care must be centered on the needs of the individual throughout his or her life, supporting the individual's capability to improve health and well-being, to predict and prevent chronic disease, and to treat it effectively and coherently when it occurs. Approaches to care must be evidence based, yet caring and compassion- ate. Fortunately, many such integrative approaches already exist on which demonstration projects might be built to identify and validate the best integrative solutions to the various health care delivery needs. This publication captures many of the deliberations and suggestions offered by participants as to possible next steps. As such it can be used as a touchstone not only for the meeting participants energized by their ex- perience, but by others far beyond the meeting who are likewise commit- ted to transformative change on behalf of better health. What better purpose to drive the focus of our attention on the path for rational atten- tion to health care reform that cultivates health as a value for each of us and for society? Ralph Snyderman, M.D. Chair, Planning Committee for the Summit On Integrative Medicine and the Health of the Public July 10, 2009

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Acknowledgments This publication is the product of the efforts of many individuals, and the Institute of Medicine (IOM) is grateful to all who contributed to the success of the summit. Recognition must first go to the Bravewell Collaborative, which made the summit possible through its generous funding and its vision to integrate health and healing into the practice of medicine. The commitment and wisdom of the members of the summit plan- ning committee must be acknowledged. With Ralph Snyderman’s leader- ship as chair, the planning committee assembled an agenda of distinguished speakers, whose presentations informed and inspired everyone. Thanks are also owed to the authors of the papers commis- sioned by the IOM, which provided background for the discussions, and to Neil and Vicki Weisfeld, who captured and organized the summit dis- cussions into this text. Throughout the course of the project, several dedicated staff mem- bers supported the planning and execution of the summit. Andrea Schultz and Samantha Chao provided steadfast support to the planning commit- tee and project, while Michael McGinnis and Judith Salerno offered their guidance and leadership. Thanks go to Katharine Bothner for her re- search assistance; to Joi Washington, Judy Estep, and Catherine Zweig for their administrative support; and to Cindy Mitchell for her incredible support to the contributions of the summit chair. Considerable apprecia- tion is also given to Donna Duncan, Michael Hamilton, and Zimika Stewart for skillfully managing the summit logistics. Additional thanks go to the numerous IOM staff members who con- tributed to the execution of the summit and to the production and dis- semination of this publication: Clyde Behney, Christie Bell, Savannah xv

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xvi ACKNOWLEDGMENTS Briscoe, Patrick Burke, Jody Evans, Dorea Ferris, Bronwyn Schrecker Jamrok, Abbey Meltzer, Patsy Powell, Marty Perreault, Autumn Rose, Christine Stencel, Janet Stoll, Ariel Suarez, Vilija Teel, Lauren Tobias, Jackie Turner, Ellen Urbanski, Danitza Valdivia, Julie Wiltshire, Sarah Widner, and Jordan Wyndelts. Finally, the insight and enthusiasm contributed by each individual who attended the three-day summit also must be recognized. The success of the summit would not have been so great without each attendee’s active participation.

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Contents SUMMARY 1 1 SUMMIT OVERVIEW AND BACKGROUND 23 Introduction, 23 The Summit on Integrative Medicine and the Health of the Public, 26 Welcome and Charge to Summit Participants, 27 Harvey V. Fineberg Keynote on Integrating Health and Health Care, 29 Ralph Snyderman 2 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE 37 Panel on the Vision for Integrative Medicine, 38 Panel Introduction, 38 Michael M. E. Johns Health Promotion and Disease Prevention, 39 William D. Novelli Integrative Infrastructure and Systems, 41 George Halvorson The Doctor of the Future, 42 Victor S. Sierpina Integrative Health and Cancer, 44 Ellen L. Stovall Communicating Health, 46 Mehmet Oz Panel Discussion, 48 Priority Assessment Group Report, 49 xvii

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xviii CONTENTS 3 MODELS OF CARE 53 Models Keynote Address, 54 Donald Berwick Panel on Models of Care, 59 Panel Introduction, 59 Erminia Guarneri Models That Integrate Continuous Care Across Caregivers and Settings, 60 Edward Wagner Care Models That Lower Per Capita Spending and Improve Outcomes, 62 Arnold Milstein Models That Promote Health, Wellness, and Preventions, 64 David L. Katz Models That Optimize Health and Healing Across the Life Span, 66 Tracy Gaudet Models That Promote Primary Care, Medical Homes, and Patient-Centered Care, 68 Mike Magee Panel Discussion, 72 Priority Assessment Group Report, 74 4 SCIENCE 77 Science Keynote Address, 78 Dean Ornish Panel on the Science Base for Integrative Medicine, 90 Panel Introduction, 90 Bruce S. McEwen Social Determinants of Health, 91 Nancy E. Adler Mind–Body Medicine, 96 Esther M. Sternberg Genomic and Predictive Medicine, 98 Richard P. Lifton Environmental Epigenetics, 100 Mitchell L. Gaynor Intervention Evaluation and Outcomes Measures, 102 Lawrence W. Green

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xix CONTENTS Modalities in Complementary and Alternative Medicine, 104 Josephine P. Briggs Panel Discussion, 106 Priority Assessment Group Report, 108 5 WORKFORCE AND EDUCATION 111 Workforce and Education Keynote Address, 112 Carol M. Black Panel on Workforce and Education, 118 Panel Introduction, 118 Elizabeth A. Goldblatt Education Curricula, 119 Mary Jo Kreitzer Core Competencies, 121 Victoria Maizes Interprofessional Education, 123 Adam Perlman Workforce Reorientation, 124 Richard A. Cooper Standards, Regulation, and Patient Safety, 125 Cyril Chantler Panel Discussion, 128 Priority Assessment Group Report, 130 6 ECONOMICS AND POLICY 133 Economics Keynote Address, 134 Senator Tom Harkin Panel on Economics and Policy, 138 Panel Introduction, 138 Sean Tunis Economic Burden of Chronic Disease, 138 Kenneth Thorpe Insurer Perspective, 140 Reed V. Tuckson Business Community Perspective, 142 Thomas J. Donohue Employer Perspective, 143 William W. George Behavior Change Incentives and Approaches, 145 Janet R. Kahn

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xx CONTENTS Rewards of Integrative Medicine, 147 Kenneth R. Pelletier Panel Discussion, 150 Priority Assessment Group Report, 152 7 CONCLUDING COMMENTS 155 Panel Moderators, 155 Michael M. E. Johns, 155 Erminia Guarneri, 157 Bruce S. McEwen, 158 Elizabeth A. Goldblatt, 159 Sean Tunis, 161 Panel Discussion, 162 Closing Remarks, 163 Ralph Snyderman and Harvey V. Fineberg APPENDIXES A References 165 B Meeting Agenda 175 C Priority Assessment Group Participants and Luncheon Discussion Leaders 183 D Speaker and Staff Biographies 187 E Issue Background Material 207

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Table, Figures, and Boxes TABLE 2-1 How the Doctor of the Future Will Function, 43 FIGURES 1-1 The inflection curve demonstrating the dynamic nature of chronic disease, 33 2-1 The square wave life curve, 38 2-2 Care that revolves around you, 41 3-1 Doctor–hospital loop, 70 3-2 Home-centered care team loop, 71 4-1 Mean percentage diameter stenosis in treatment and control groups at baseline, 1 year, and 5 years, 83 4-2 Hippocampus volume change, 85 4-3 Increase in telomerase activity from baseline to 3 months, 86 4-4 Cumulative mortality for depressed and nondepressed patients, 89 4-5 The stress response and development of allostatic load, 90 4-6a,b Relationship between income and education and reported adult health status, 93 4-7a,b Relationship between income and education and reported child health status, 94 xxi

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xxii TABLE, FIGURES, AND BOXES 4-8 Mean telomere length and standard error by manual vs. nonmanual social class groupings, 95 4-9 Evidence-based medicine and integrative, patient-centered medicine, 103 4-10 NCCAM’s mission: Building the evidence base for integrative medicine, 105 5-1 Competency framework: Working with others, 116 5-2 Decrease in empathy among medical students, 131 BOXES S-1 Recurring Summit Perspectives on Integrative Medicine, 5 1-1 The Inflection Curve Case Study, 33 3-1 Berwick’s Principles for Integrative Medicine, 57 E-1 Commissioned Background Material for the Summit, 207